The First DraftV 1.0

Released byTHE SOCIETY OF CLINICAL NUTRITION

AND METABOLISM

Chairperson: Dr N. MariappanRetired Plastic Surgeon, Bengaluru, Karnataka, India

Dr Shobha ChamaniaHead of the Department, Burn Surgery Unit, Choithram Hospital and Research Center Indore, Madhya Pradesh, India

Dr C. S. ChamaniaHead of the Department, Department of Surgery, Choithram Hospital and Research Centre, Indore, Madhya Pradesh, India

2017

ISBN: 978-8190641722

The Indian Guidelines for Nutrition Support in Burn Patients

V1.0.

The First Draft

Released byTHE SOCIETY OF CLINICAL NUTRITION AND METABOLISM

Chairperson: Dr N. Mariappan, Retired Plastic Surgeon, Bengaluru, Karnataka, IndiaDr Shobha Chamania, Head of the Department, Burn Surgery Unit, Choithram Hospital and Research Center Indore, Madhya Pradesh, IndiaDr C. S. Chamania, Head of the Department, Department of Surgery, Choithram Hospital and Research Centre, Indore, Madhya Pradesh, India

December 2017

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DECEMBER 2017

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ContributorsPratibha Sharma, Choithram Hospital and Research Centre, 14, Manik Bagh Road, Indore-452014, Madhya PradeshDr. Mansi Patil, AshaKiran Jubilee Hope Centre Hospital No. 138, Balaji Chowk, Chinchwad East, Pune, Ma-harastra, India

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Brief Contents

1. Dietitians Role in Nutrition Support for Burn Patients 7 2. Team Work and its importance 8 3. Nutrition Plan 10

a. Identification of patients with major burns b. How to find whether patient needs nutritional therapy program? c. What are the goals of nutritional management? d. What are the objectives of nutritional management? e. When nutritional management is necessary? f. Checklist for nutrition planning

4. Education, Continuing Professional Development and Research 14 5. Psychosocial factors and family 15 6. Nutrition Support for The Burn Patients

a. Pathophysiology of Burn b. Nutritional assessment (Adults and Children) c. Mode of nutrition support d. Nutritional supplement e. Non-nutritional management of hyper metabolism f. Attenuation of Hyperglycemia in Post-Burn Patients g. Nutrition assessment tools h. Nutritional, immunological and microbiological profiles of burn patients i. Overfeeding j. Refeeding syndrome k. Early enteral feeding l. Formulas for Nutritional Management m. Discussion and Conclusions

7. Special considerations in pediatric burn patients a. Initial treatment considerations in pediatric burns

i. Admission criteria ii. Inhalation injury

iii. Burn depth iv. Superficial partial thickness v. Electrical injuries

vi. Chemical burns b. Fluid Resuscitation c. Pain Management d. Nutrition e. Systemic antibiotics f. Management of the burn wounds

8. ESPEN Recommendations a. Route of feeding b. Energy requirements and list of formulas

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c. Proteins and specific amino-acids d. Carbohydrates and glycemic control e. Lipids f. Micronutrient requirements g. Non-nutritional management of hyper metabolism

9. ISBI Recommendations a. Nutritional assessment

i. Determining nutritional status and nutrition risk ii. Evaluating nutritional adequacy

iii. Determination of energy and protein requirements 1. Metabolic factors that influence macronutrient 2. utilization 3. Clinical factors that influence energy requirement 4. Indirect calorimetry 5. Estimation of protein needs

b. Nutrition support strategies i. Combined enteral and parenteral nutrition during the

ii. early acute phase of injury iii. Enteral feeding guidelines in early recovery iv. Parenteral nutrition composition

c. Enteral nutrition i. Formula selection

ii. Small bowel versus gastric feeds d. Micronutrient supplementation

10. Supplementary Materials a. Formulae for Assessment

i. Toronto Formula ii. Modified Harris Benedict Equation

iii. Modified Schofield Equation iv. Ireton-Jones Equation v. Curreri Formula

b. Macronutrient Requirements i. Protein

ii. Carbohydrate iii. Fat iv. Fluid

c. Macronutrient Requirements and Monitoring i. Vitamins and Minerals

ii. Monitoring d. Parenteral nutrition

i. Glucose ii. Lipid

iii. Vitamins, minerals and trace elements

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iv. TPN specific Monitoring e. ASPEN, USA Recommendations

i. What mode of nutrition support should be used to feed burn patients? ii. How should energy requirements be determined in burn patients?

iii. What is the optimal quantity of protein to deliver to patients with large burns requiring ICU care?

iv. When should nutrition support be initiated?

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Background Burn injuries account for an estimated 180000 deaths per annum (World Health Organization). The major incidents occur in low and middle-income economies, and half of the incidents take place in South – East Asia Region. As per WHO report 2014, in India, over 1, 000, 000 people are moderately or severely burnt every year (National Programme on Prevention and Management of Burn Injuries, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India). International guidelines regarding nutrition management for burn patients have been mostly derived from studies done in their respective countries. The most well-known evidence-based burn nutrition guidelines were developed by The International Society for Burn Injuries (ISBI) (Prelack et al. 2007) and European Society for Clinical Nutrition and Metabolism (Rousseau, 2013). Very few studies were done in India related to the Nutrition Management for Burn Patients. In the year 2017, IAPEN decided to release the first draft of burn nutrition guidelines and The Nutrition Support Certification Board of IAPEN accepted the manuscript titled "Nutrition in burns patient" to be the base document for preparation of the first draft of the Indian Guidelines for Nutrition Support for the Burn Patients V1.0. The manuscript was published in the "IOSR Journal of Dental and Medical Sciences" in the year 2015. The authors of the manuscript are Dr. Mariappan Natarajan, Associate Professor of Plastic Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru. and Dr. D.R. Sekhar, Professor and HOD Department of Plastic Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru. On September 11, 2017, IAPEN has invited many Burn Surgeons throughout India, Bangladesh and Nepal for giving inputs to this important document. These consensus statements were prepared with the help of the following standard guidelines and inputs from Burn Surgeons throughout India.

1. The International Society for Burn Injuries: Prelack, K., Dylewski, M., & Sheridan, R. L. (2007). Practical guidelines for nutritional management of burn injury and recovery. burns, 33(1), 14-24.

2. European Society for Clinical Nutrition and Metabolism: Rousseau, A. F. Losser, M. R., Ichai C. & Berger, M.M. (2013). ESPEN endorsed recommendations: nutritional therapy in major burns. Clinical nutrition, 32(4), 497-502.

3. Nutrition in burns patient, Dr. Mariappan Natarajan, Associate Professor of Plastic Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru. and Dr. D.R. Sekhar, Professor and HOD Department of Plastic Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), Volume 14, Issue 3 Ver. VII (Mar. 2015), PP 38-54.

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4. Special considerations in pediatric burn patients, Sharma, R. K., & Parashar, A. (2010) Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India, 43 (Suppl), S43. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038395/)

5. Nutritional concerns in critically ill burn patients, Bajwa S. J. S., & Kaur, G. (2015) Journal of Medical Nutrition and Nutraceuticals, 4(2), 70-76.

6. McClave, S. A., Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., ... & American College of Critical Care Medicine. (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 33(3), 277-316.

7. Clinical Practice Guidelines Nutrition Burn Patient Management, NSW Statewide Burn Injury Service, Agency for Clinical Innovation, K A’Beckett, L Baytieh, A Carr-Thompson, V Fox, P MacLennan, J Marriott, C Nicholls & N Petrunoff, Anne Darton, 2011, Chatswood, New South Wales, Australia (https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf).

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Dietitians Role in Nutrition Support for Burn Patients The dietitian’s role in the multidisciplinary burn team in the assessment, treatment and management of nutrition problems arising from burn and inhalation injuries is now well established in burns literature. These guidelines reflect the essential role the dietitian or nutrition support clinician has in the provision of specialized nutritional support to promote recovery from burn injuries. India do not have sufficient number of dietitians or nutrition support clinicians. IAPEN Current Recommendations

1. Dietitians can refer to this first draft of burn guidelines for treating patients with burn injuries.

2. Medical officers can undergo special burn nutrition training offered by IAPEN for Nutrition Support for the Burn Patients (7 Days).

3. Nurses, Pharma or employee with related specializations working in Burn Wards can undergo Basic Burn Nutrition Training offered by IAPEN for Nutrition Support for The Burn Patients (15 Days Training) (Email to info@iapen.co.in for more information).

Reference:

1. Clinical Practice Guidelines Nutrition Burn Patient Management, NSW Statewide Burn Injury Service, Agency for Clinical Innovation, K A’Beckett, L Baytieh, A Carr-Thompson, V Fox, P MacLennan, J Marriott, C Nicholls & N Petrunoff, Anne Darton, 2011, Chatswood, New South Wales, Australia (https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf).

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Team Work Burn centre’s provide specialist, multidisciplinary care in the management of burn injuries. Sometimes, the primary care or follow up treatment of burn injuries may need to occur outside of specialist units. Burn wards in India are managed by Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India. The following are the list of required specialties and man power suggested by the National Programme on Prevention and Management of Burn Injuries, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India in their Operational Guidelines for Establishment of Burns Units at Medical Colleges in India.

Name of Post Number Burns & Plastic Surgeons/General Surgeon 1Anesthetist 2 Medical Officer (Preferably with MS in Surgery) 4Staff Nurses 12OT Technician 1Multipurpose Rehabilitation/CBR Workers 2 Dresser 1 Data Entry Operator for Burn Registry 2 Multipurpose workers (Nursing orderly/ Nursing attendants/ Safai Karamchar 10

Total 35 Any guidelines to be adopted in any Burn Centre in India should consider the man power availability based on the above table. Many hospitals with burn wards in India do not have Department of Dietetics or Department of Clinical Nutrition. IAPEN Recommendations

1. A multidisciplinary team involving various departments in the hospital based on the availability and the patient’s financial capability has to be formed for treating burn injuries. The basic team should involve, patient, plastic surgeon or general surgeon, anaesthetist, dietitians or nutritionists or trained medical officer, domestic staff, health workers, intensivists and nurses.

2. Dentist, orthopedic doctors, pediatrician, pharmacists, physiotherapists, psychiatrists and doctors specialized in rehabilitation can be called based on the requirements and case to case basis.

3. Special training to the Medical Officers working in burn ward on advanced clinical nutrition by IAPEN

4. Basic training to the nurses or multipurpose workers by IAPEN.

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References: 1. Clinical Practice Guidelines Nutrition Burn Patient Management, NSW Statewide

Burn Injury Service, Agency for Clinical Innovation, K A’Beckett, L Baytieh, A Carr-Thompson, V Fox, P MacLennan, J Marriott, C Nicholls & N Petrunoff, Anne Darton, 2011, Chatswood, New South Wales, Australia (https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf).

2. Operational Guidelines for Establishment of Burns Units at Medical Colleges under NPPMBI, Government of India http://dghs.gov.in/WriteReadData/userfiles/file/Operational_Guidlines_Medical_College.pdf

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Nutrition Plan Burns management needs multidisciplinary approach with efforts from various specialties in the team. The dietitian or nutrition support clinician in the burn team has a defined role in the care of the burn patients, from the acute phase followed through the rehabilitation. Their role in the assessment, treatment and management of nutritional requirements with or without inhalation injuries is followed in the unit. Burns patients typically have the hyper metabolism and negative catabolism. Nutritional support is an important step in the management of burns patients from the early phase of resuscitation to the final phase of rehabilitation. The pathophysiology of burn injury with its major endocrine, inflammatory, metabolic and immune alterations is similar to any other critical care situation. The route of administration and aggressiveness of the delivery of the nutrients depends on the severity of the patient’s illness and the response of the particular patient. The plan of nutritional support to the patient during the whole period of stay in the hospital varies depending on the clinical condition of the patient. The treatment protocols are evidence based depending on the clinical and laboratory studies. Nutritional support is defined as the provision of nutrients and any necessary adjunctive therapeutic agents to improve or maintain the nutritional status of the patient for normal wound healing. Nutritional support is administered into the stomach or small intestine (enteral) and/or by intravenous infusion (parenteral). Most of the burn victims with lesser percentage of burns can be followed in the outpatient department. Less than 10% of the patients with burn injuries need in patient treatment. Very few patients only require intensive care treatment. Patients with major burns are those with more than 20% total body surface area burn with or without inhalation injury. Patients with major burns are characterized by • Strong oxidative stress • Intense inflammatory response • Prolonged periods of hyper metabolic and catabolic response How to find whether patient needs nutritional therapy program? Patients with 25% burns are characterized by

• Metabolic rate is elevated to 118% to 210% in adults • Resting metabolic rate elevated to approximately 180% • Calorie needs may exceed 5000 Kcal/day • Without nutritional support 40% burns patient lose 25% of pre-admission weight in 3

weeks,

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• Impaired immunity and delayed healing This characteristic metabolic change associated with burns indicates the need for a nutritional therapy program from the day of the injury. What are the goals of nutritional management? Goals of nutritional management

Optimal wound healing and rapid recovery from burn injuries Minimize complications including infection To attain and maintain normal nutritional status To minimize the metabolic disturbances during the treatment process.

What are the objectives of nutritional management? Objectives of nutritional management

• Provide nutrition via enteral route within 6-18 hours post burn injury • Maintain weight within 5% -10% of pre-burn weight • Prevent micronutrient deficiency • Minimize hyperglycemia • Minimize hypertriglyceridemia.

When nutritional management is necessary? There is a significant damage to the gut mucosa and translocation of the gut bacteria following major burn injuries. This leads to the decreased nutrient absorption. Enteral nutrition (EN) started earlier (within 24 hours of burn injury) results in good outcome for the patients. With early institution of enteral nutrition there is a significant modulation of catecholamine levels and support of gut mucosal integrity. With the early institution and by continuous enteral nutrition, by 3rd post-burn day there is an adequate supply of caloric requirements, reduction of plasma cortisol and glucagon levels and reduction of hyper metabolic response. Post burn ileus affects the stomach and colon primarily. Patients with major burn injuries can be fed through enteral tubes to the duodenum or jejunum as early as 6 hours post burn. Early EN maintains gut integrity, motility and blood flow and helps to prevent intestinal hypo perfusion or ileus due to delays in resuscitation or reperfusion. The American burn association recommended early enteral nutrition during the acute phase of the burn within the 24 hours post burn. Peng et al. found markedly increased intestinal permeability in severely burnt patients by lactulose and mannitol measurements. Early enteral feedings reduce the excessive permeability and associated with lower levels of serum endotoxin and TNF-alpha compared to the delayed enteral fed patients.

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Reference: 1. Nutrition in burns patient, Dr. Mariappan Natarajan, Associate Professor of Plastic

Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru. and Dr. D.R. Sekhar, Professor and HOD Department of Plastic Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), Volume 14, Issue 3 Ver. VII (Mar. 2015), PP 38-54.

Checklist for nutrition planning The nutrition plan must be compatible with other treatment. The team members along with dietitian should implement the nutrition plan that considers the below aspects.

• The status and location of wounds • The process of skin replacement • Respiratory needs and lung function status • Nutritional and physical status prior to injury • Pyrexia • Gastrointestinal function • The psychosocial status of the patient and family • The age and gender of the patient • The level of alertness of the patient • Pain management and sedation • Individual patient factors, such as compliance and individual priorities, the presence

of pre-injury behavioral problems, psychological or psychiatric history, learning disabilities or developmental delay, and previous hospitalization experiences

• Indications for treatment variance, such as reconstructive surgery, psychological changes etc

• Cultural background and religious beliefs • The responses of partners, parents, caregivers and family members • Special dietary needs e.g., food allergies

Treatment complications, Treatment planning, Occupational Health & Safety and infection control The nutrition support clinician or dietitian needs to demonstrate awareness of the potential deleterious effect of dietary regimens if incorrectly applied or not applied in a timely manner. Team approach is recommended in this regard. The dietitian must be aware of the occupational health and safety guidelines and infection control procedures.

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Reference 1. Clinical Practice Guidelines Nutrition Burn Patient Management, NSW Statewide Burn

Injury Service, Agency for Clinical Innovation, K A’Beckett, L Baytieh, A Carr-Thompson, V Fox, P MacLennan, J Marriott, C Nicholls & N Petrunoff, Anne Darton, 2011, Chatswood, New South Wales, Australia

(https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf). ESPEN Recommendations: Nutritional therapy should be initiated early within 12 h of injury, preferentially by the enteral route References:

1. European Society for Clinical Nutrition and Metabolism: Rousseau, A. F. Losser, M. R., Ichai C. & Berger, M.M. (2013). ESPEN endorsed recommendations: nutritional therapy in major burns. Clinical nutrition, 32(4), 497-502.

http://www.clinicalnutritionjournal.com/article/S0261-5614(13)00076-9/fulltext

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Education, Continuing Professional Development and Research Dietitian or nutrition support clinician should educate the patient, staff and care providers during the treatment process. The dietitian or nutrition support clinician should continuously update his or her knowledge in the area of advanced clinical nutrition. IAPEN Recommendations Due to extensive workload in all burn wards throughout India, it is practically not possible for any staff to continuously participate in lifelong learning. IAPEN strongly recommends 10 days On-Official Duty Leave per six months for all employees (Including OT Technician, Multipurpose Rehabilitation/CBR Workers, Dresser, Data Entry Operator for Burn Registry, Multipurpose workers) in the burn ward for lifelong learning. IAPEN also recommends the organizations to give full financial support for attending conferences, workshops or seminars or internships or joining any courses. IAPEN will try helping people in training and knowledge transfer through tailor made short term programs to the staff working in burn wards. We also welcome other organizations to promote knowledge transfer by offering many courses in burn nutrition planning and management. May be in future, IAPEN will recommend burn wards to start research and development facilities. Reference

1. Clinical Practice Guidelines Nutrition Burn Patient Management, NSW Statewide Burn Injury Service, Agency for Clinical Innovation, K A’Beckett, L Baytieh, A Carr-Thompson, V Fox, P MacLennan, J Marriott, C Nicholls & N Petrunoff, Anne Darton, 2011, Chatswood, New South Wales, Australia

(https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf)

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Psychosocial factors and family The dietitian must attempt to identify psychosocial factors, family characteristics and events happened in past that will impact on successful treatment outcomes. The dietitian should also concentrate on patient’s acceptance of changes to their physical and social function. Reference

1. Clinical Practice Guidelines Nutrition Burn Patient Management, NSW Statewide Burn Injury Service, Agency for Clinical Innovation, K A’Beckett, L Baytieh, A Carr-Thompson, V Fox, P MacLennan, J Marriott, C Nicholls & N Petrunoff, Anne Darton, 2011, Chatswood, New South Wales, Australia

(https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf)

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Nutrition in Burn Patients http://www.iosrjournals.org/iosr-jdms/papers/Vol14-

issue3/Version-7/H014373854.pdf

Special considerations in paediatric burn patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038395/

ESPEN endorsed recommendations: nutritional therapy in major burns

http://www.burnsjournal.com/article/S0305-4179(06)00202-

6/pdf

ISBI -Practical guidelines for nutritional management of burn injury and recovery

http://www.burnsjournal.com/article/S0305-4179(06)00202-

6/pdf

Supplementary Material https://www.aci.health.nsw.gov.au/__data/assets/

pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf

ASPEN Burn Nutrition Guidelines

http://www.iapen.co.in/aspen-burn-nutrition-guidelines.pdf